PROTECTED WHEN COMPLETED - B

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FAMILY INFORMATION
Type of application: Visitor Worker ✔ Student Other

Complete ALL names in English and in your native language (for example, Arabic, Cyrillic, Chinese, Chinese commercial/telegraphic code, Korean, or
Japanese characters). Include ALL family members even if they are not accompanying you. If you need more space for any section, print out an additional
page containing the appropriate section, complete and submit it with your application.

BEFORE YOU START, READ THE INSTRUCTION GUIDE, TYPE OR PRINT IN BLACK INK.
SECTION A
Will accompany
Relationship Date of birth Present address
Name you to Canada?
SEE NOTE 1 (YYYY-MM-DD) (if deceased: give city/town, country and date)
YES NO

Kausar Ahmed Rohan 2003-07-24 Lakhaura, Airport, Lakhaura-3100, Sylhet

Applicant Country of birth:
Marital status: Bangladesh Present occupation:
Single
student
N/A
Spouse or
common-law Country of birth: ✔
Marital status: partner Present occupation:

Syeda Farjana Islam Rima 1983-05-01 Lakhaura, Airport, Lakhaura-3100, Sylhet

Mother Country of birth: ✔
Marital status: Bangladesh Present occupation:
Married
House wife
Md Harun Mia 1973-10-11 Lakhaura, Airport, Lakhaura-3100, Sylhet
Father Country of birth: ✔
Marital status: Bangladesh Present occupation:
Business
NOTE 1: If no spouse or common-law partner is listed in Section A, read and sign below.

I certify that I do not have a spouse or a common-law partner.

Signature: Date (YYYY-MM-DD)

SECTION B - CHILDREN (Include ALL sons and daughters, including ALL adopted and step-children, regardless of age or place of residence)
Will accompany
Relationship Date of birth Present address
Name you to Canada?
SEE NOTE 2 (YYYY-MM-DD) (if deceased: give city/town, country and date)
YES NO

Country of birth:
Marital status: Present occupation:

Country of birth:
Marital status: Present occupation:

Country of birth:
Marital status: Present occupation:

Country of birth:
Marital status: Present occupation:

NOTE 2: If no children are listed in Section B, read and sign below.

I certify that I do not have any natural, adopted nor step-children.

Signature: Date (YYYY-MM-DD)

IMM 5645 (01-2021) E (DISPONIBLE EN FRANÇAIS - IMM 5645 F)

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SECTION C - BROTHERS AND SISTERS (Include ALL brothers and sisters, ALL half-brother and sister and stepbrother and sister.)
Will accompany
Relationship Date of birth Present address
Name you to Canada?
SEE NOTE 2 (YYYY-MM-DD) (if deceased: give city/town, country and date)
YES NO

Country of birth:
Marital status: Present occupation:

Country of birth:
Marital status: Present occupation:

Country of birth:
Marital status: Present occupation:

Country of birth:
Marital status: Present occupation:

Country of birth:
Marital status: Present occupation:

Country of birth:
Marital status: Present occupation:

Country of birth:
Marital status: Present occupation:

SECTION D - CERTIFICATION

I certify that the information contained in this document is complete, accurate and factual. I also realize that once this document has been completed and signed that it
will form part of my Immigration Record and will be used to verify my family details on future applications.

Signature: Date (YYYY-MM-DD)

Personal information provided on this form is collected by Immigration, Refugees, and Citizenship Canada (IRCC) under the authority of the Immigration and Refugee Protection Act
(IRPA). The personal information provided will be used for the purpose of processing an application. The personal information provided may be disclosed to other federal
government institutions, law enforcement bodies, provincial/territorial governments, foreign governments for the purpose of validating identity, eligibility and admissibility. The
personal information may also be disclosed to medical practitioners for the purpose of validating identity and eligibility.

Personal information may also be used for other purposes including research, statistics, program and policy evaluation, internal audit, compliance, risk management, subsequent
program eligibility, and strategy development and reporting.

Failure to complete the form in full may result in a delay or the application not being processed. The Privacy Act gives individuals the right of access to, protection, and correction of
their personal information. If you are not satisfied with the manner in which IRCC handles your personal information, you may exercise your right to file a complaint to the Office of
the Privacy Commissioner of Canada. The collection, use, disclosure and retention of your personal information is further described in IRCC’s Personal Information Bank – IRCC
PPU 013, 051, 068.

IMM 5645 (01-2021) E